Success hinges on preoperative selection criteria and advanced arthroscopic techniques, study finds

Managing shoulder instability in athletes younger than 22 years of age can be challenging due to the high failure rates associated with nonoperative treatment and the high recurrence and low return-to-sport (RTS) rates following arthroscopic shoulder stabilization. Research presented during the American Orthopaedic Society for Sports Medicine 2018 Annual Meeting, however, indicates that reserving arthroscopic shoulder stabilization for athletes with three or fewer episodes of preoperative instability can improve outcomes in this patient population. Open surgery was considered for high-risk athletes with more than three episodes of instability, and bone augmentation surgery was performed in those with significant bone loss and bipolar lesions.

“Our study highlights the importance for young athletes with shoulder instability to have a thorough preoperative evaluation to determine the number of instability events, obtain appropriate advanced imaging when significant bone loss is suspected, and be treated with advanced arthroscopic techniques, including a posteroinferior capsulolabral repair, when indicated,” said the study’s lead author, Frank A. Cordasco, MD, MS, of the Hospital for Special Surgery in New York City. “Each preoperative instability episode can result in greater degrees of bone loss, which result in higher failure rates following arthroscopic shoulder stabilization.”

Dr. Cordasco and colleagues reported the outcomes of a prospective case series comprised of 63 high-risk athletes (67 shoulders) younger than 22 years of age (mean age, 17.5 years; 76 percent male) whose shoulder instability was treated with arthroscopic anterior stabilization in the beach chair position by a single surgeon. Patients with more than three preoperative episodes of instability, significant bone loss, engaging or off-track patterns of instability, or primary posterior instability were excluded.

The researchers collected demographic data for all patients, including age, sex, body mass index, last recorded range of motion, number of episodes of recurrent instability, and revision surgery. They surveyed patients to obtain the following information:

• shoulder instability history
• sports prior to surgery
• sports returned to following surgery
• satisfaction with and level of RTS
• time at which RTS was achieved
• recurrent instability
• revision surgeries
• single assessment numeric evaluation (SANE) score

The primary outcomes were RTS and revision surgery following arthroscopic shoulder stabilization at two-year minimum follow-up.

Football and baseball were the most common sports to which young athletes returned, at an average of 7.8 months, following arthroscopic shoulder stabilization.

The mean number of instability events was 1.2 (range, zero–three); 59 percent occurred in the dominant arm. Arthroscopic stabilization was performed with a mattress suture technique with knotless polyetheretherketone anchors. All athletes were treated with anterior capsulolabral repair, and 67 percent (n = 42) received a concomitant posteroinferior capsulolabral repair. The number of anchors averaged 3.6 per patient.

The overall RTS rate was 87
percent (n = 55), with 79 percent (n = 50) returning to the same or higher level of play at an average of 7.8 months (range, five–12 months) after arthroscopic stabilization. Males and females had no significant differences in RTS rate (88 percent and 87 percent, respectively). The most common sports were football and lacrosse.

Analysis revealed sex-specific differences with respect to revision surgery. Overall, 42 patients (67 percent) were indicated for surgery after their first dislocation. Among the four athletes (6 percent) who underwent revision stabilization at 11–36 months for recurrent instability, all were male, and all had more than one preoperative episode of instability.

The patient-reported mean SANE score was 88.

The researchers believe that the improved outcomes are directly related to the study’s preoperative selection criteria and the use of advanced arthroscopic techniques.

“This preoperative approach can determine the best procedure to select from the menu of options available (advanced arthroscopic stabilization, open stabilization, or bone augmentation, such as the Latarjet reconstruction) to manage shoulder instability in young athletes and get them back in the game. The results of our study demonstrate that when the high-risk athlete younger than 22 years of age with three or fewer episodes of preoperative instability is treated with an arthroscopic stabilization, the revision surgery rate is low and the RTS rate is high. Arthroscopic shoulder stabilization may offer the best outcomes in this group when it is performed after the first dislocation, as all four athletes who required revision surgery had more than one preoperative episode of instability. Additional research is needed to continue to improve outcomes for this challenging, high-risk group of athletes,” said Dr. Cordasco.

Dr. Cordasco’s coauthors of “Arthroscopic Shoulder Stabilization in the High-risk Young Athlete: Return to Sport and Second Surgery Rates” are Brian Lin, BS; Michael Heller, ATC, BES, CES; Lori Ann Asaro, PA-C, MS; Daphne Ling, PhD, MPH; and Jacob G. Calcei, MD.

Bottom Line

• In this study, researchers evaluated two-year clinical outcomes in high-risk athletes younger than 22 years of age following arthroscopic shoulder stabilization. Primary outcomes were RTS and revision surgery.
• They found a high RTS rate and low revision surgery rate when arthroscopic shoulder stabilization was performed in athletes with three or fewer episodes of preoperative instability.
• The results highlight the importance of a preoperative evaluation to determine the number of instability events, get advanced imaging when bone loss is suspected, and apply advanced arthroscopic techniques, including posteroinferior capsulolabral repair, when indicated in this high-risk athletic population.

Maureen Leahy is the former assistant managing editor of AAOS Now.